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Abstract: Reisinger, Marc & Picard, Eric, (1996), Reisinger, Marc (1995), Reisinger, Marc (1997)
Heroin addiction represents a major public health problem that first began to reach epidemic proportions in Belgium in the mid 1970's. In 1975 the government of Belgium passed a law that prohibited physicians from writing prescriptions for addictive medicines for heroin addicted patients. In 1976 the Belgium Medical Association published a document that discussed the treatment of drug addiction in relation to the new repressiveness of the law. The BMA document argued that from a legal standpoint, physicians have the therapeutic freedom as well as the medical responsibility to undertake the treatment of individuals suffering from problems associated with drug addiction. The document further argued that any physician who decides to voluntarily undertake the treatment of a drug addicted individual maintains the therapeutic freedom to determine the type of treatment to be provided.
With this concept of therapeutic freedom in mind, Belgian physicians in the 1980's began prescribing methadone to heroin addicts who came to their offices to seek treatment for their addiction. The use of methadone as a treatment for individuals addicted to heroin was spearheaded by the outbreak of the HIV/AIDS epidemic. Medical professionals in Belgium estimate that between 500 and 1000 of the 3,500 heroin addicted individuals in the country derived significant positive benefits from methadone treatment during this period.
Despite the fact that methadone treatment was shown to be of substantial benefit to Belgian heroin addicts among the small minority of Belgian physicians who were aware of this therapeutic approach, few were willing to get involved. The unwillingness by the majority of Belgian physicians to provide methadone treatment to those suffering from drug addiction led most heroin addicts who needed medical care during the early eighties to seek help from a small number of general practitioners and psychiatrists who lacked the specialized skills and knowledge to treat their addiction optimally. Some Belgian heroin addicts were prescribed extremely high doses of injectable methadone and other narcotics which were subsequently diverted. Methadone began to be associated with numerous cases of death caused by drug overdose, and caused Belgian legal authorities to take further repressive action to stop physicians from prescribing. A major crackdown on methadone prescribing was associated with the arrest and convictions of doctors charged with assisting the maintenance of drug addiction and many served time in prison. Further repressive action came from the Belgian Medical Association, which in August 1986 revamped its therapeutic freedom proclamation of ten years prior, to impose strict limits on physicians right to prescribe methadone. As a result of this action by the BMA, methadone maintenance treatment became almost completely unavailable in Belgium between 1983 and 1990. There was only one exception: a specialized treatment center, Project LAMA, that was authorized to dispense methadone and buprenorphine to a population of one hundred medically supervised heroin addicts.
The repressive actions of the Belgian Medical Association to control the therapeutic freedom of physicians to prescribe methadone had profound consequences for the public health. In 1990 police authorities in Belgium estimated that there were somewhere between eight and fifteen thousand addicts in Brussels who were in need of treatment, and only about 150 BMA - approved treatment slots available. Later that same year, Dr. Marc Reisinger, a psychiatrist in private practice in Brussels and vice president of the European Opiate Addiction Treatment Association, began legal action before the Belgian Council of State to demand the nullification of BMA regulations associated with methadone treatment and in 1993 the regulations were overturned. The Council appointed Dr. Reisinger to analyze the methadone treatment situation and report his findings to the Belgian Minister of Health. A detailed analysis followed, with the strong recommendation that maintenance treatment for addicted patients should be expanded nationwide, and that general practitioners should have a significant role in the treatment process.
In 1994 a Consensus Conference on Methadone Maintenance Treatment was organized by the Minister of Health to evaluate and assess the status of the methadone maintenance treatment situation in the country. The report of the conference was sent to every physician in Belgium, and the major conclusions were as follows:
Recognition of Methadone as a Legitimate Medical Treatment for Heroin Addiction in Belgium
The adoption of official therapeutic guidelines developed by the 1994 consensus panel represented a significant first step toward the recognition of methadone as a legitimate treatment for heroin addiction in Belgium. Methadone began to be seen as a very effective, ordinary medication that serves to reduce the individual's consumption of injectable heroin. The new guidelines suggested standards for methadone dosage and duration of treatment, but permitted physicians to adapt them to fit the needs of each individual patient. The guidelines also specified that short term methadone treatment was only appropriate in limited circumstances and that daily administration of the drug under supervision is only recommended at the beginning phase of treatment and can usually take place in a pharmacy chosen by the patient. The guidelines also allow physicians in Belgium the therapeutic freedom to prescribe larger quantities of methadone at less frequent intervals depending upon the patient's progress.
According to research findings of Drs. Marc Reisinger and Eric Picard, the number of patients currently receiving methadone treatment in Belgium is only about five thousand out of an estimated total of twenty to thirty thousand heroin users. However, the number in treatment is growing rapidly. More than eighty percent of methadone patients receive their treatment from private general practitioners. Some five hundred primary care physicians presently prescribe methadone. Methadone is also readily available to the patients by the city's pharmacists, who actively work with the primary care physicians to provide the most efficacious therapy. Most patients are able to get a one to two week supply of the drug. As a precautionary measure, regional departments supervised by the Belgian Ministry of Health are required to verify and monitor every prescription for methadone filled by pharmacists so as to prevent the same patient from receiving multiple prescriptions for the medication.
The increased availability of methadone at local pharmacies in Belgium has also been associated with a significant decline in drug overdoses and criminal behavior among patients. Based on these findings, Reisinger & Picard conclude that the flexible method of prescribing methadone utilized in Belgium today has resolved some of the social and political problems associated with drug. Yet, flexible prescribing of methadone is still controversial in Belgium. Some opponents fear that the approach will lead to a resurgence of long-standing problems of drug trafficking, overdose, and prescription abuse that have been associated with the use of methadone in other countries, such as the United States.
Reisinger, Marc & Picard, Eric, (1996) Methadone in Belgium: Regaining therapeutic freedom in Addiction Research Vol. 3(4) pp. 369-374.
Reisinger, Marc, (1995) Methadone as Normal Medicine, Paper presented at the European Methadone Association Forum, AMTA Methadone Conference Phoenix Arizona October.
Reisinger, Marc, (1997) Interview about Methadone Maintenance Treatment in Belgium in the Malta Messenger, Vol. 5(3), Summer/Fall issue.